Which office will you visit? (If the office you plan to visit is not listed please click "back" to return to the previous screen.)

ECC Statesville


 

Is this your first visit to this office?

Yes  No
 

Do you have an appointment scheduled?

Yes No
 

If yes, what is the date for which your appointment is scheduled?

-- dd/mm/yy
 

Personal Information:

First Name
Last Name
Middle Initial
Date of Birth
Sex	Male Female

Please provide the following contact information:

Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Employer
Work Phone
Home Phone
E-mail

How do you prefer to be contacted for additional information?

Home Phone Work Phone e-mail

Social Security # (ex: 123456789)

Insurance Information:

Insurer:

Policy #

Group #

Your relationship to insured:

Self Spouse Child/Dependent

How did you find our practice?

Friend
Insurance
Employer
Yellow Pages
Newspaper
Internet
Direct Mail
Other

 

Approximately when was your last eye examination

Who was your last eye doctor?

Have you ever worn?

glasses
contact lenses
 

Are you interested in...?

contact lenses
prescription sunglasses
new glasses
new lens technology
30-day continuous wear contacts
changing your eye color
LASIK or other refractive procedures
Optos non-dilated eye examination
 

Ocular history (YOU): Check all that apply:

headaches    
double vision
eye turn
eye surgery
eye injury
itching
redness
burning
gritty/sandy feeling
eye pain
floaters
flashing lights
glare
blurry vision
visual distortion
eyelid problems
lumps/bumps
 

Please select any of the following systems with which you now have or have had difficulties (review of systems):

Gastrointestinal      Ear/Nose/Throat       Cardiovascular        Respiratory         
Nervous               Genitourinary         Musculoskeletal       Skin                
Mental                Endocrine (glands)    Blood/lymph           Allergic/immunologic

Please select all that apply to your FAMILY history:

Hypertension          Diabetes              Glaucoma              Macular degeneration
Retinal detachment    Eye degeneration      Cataracts             Thyroid disease     
Blindness             Stroke                Cancer                Heart Disease       
Kidney disease        

Please list medications you are taking...

Are you allergic to any medications?

Yes No
 

If yes, please list medication allergies:

Please list operations you have had (if any):

Do you use cigarettes/tobacco?

Yes No
 

Do you/have you had substance abuse problems (including alcohol)?

Yes No
 

Who is your family doctor?

Is there any other health information we should know?

Please list medical conditions for which you have been treated in the past two years:

 

Payment Policy

Payment for professional services is due upon completion of services. Spectacles and contact lenses require a 50% deposit before ordering.  The balance on materials  is due when the materials are dispensed.  We do not bill services or materials.  We do accept assignment on many insurance plans.  If we do not accept assignment on your insurance plan, we will file the necessary paperwork so that payment for covered services and/or materials can be sent to you by your insurance company.

You are ultimately responsible for all charges incurred in our office, including charges for services and/or materials rejected or not covered by insurance (authorization and verification of benefits is NOT a guarantee of payment).  If we must resort to collection agencies or the court system to collect unpaid balances, you will be responsible for costs incurred in such collection.

Please read the following statements and sign (click) below:

I have read the payment policy above and agree to the terms as stated.

I have read the Notice of Privacy Practices and agree to the terms.